University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet
at www.ucop.edu/ucship or by calling 1-866-940-8306.
Important Questions
What is the overall
deductible?
Are there other
deductibles for specific
services?
Is there an out–of–
pocket limit on my
expenses?
Answers
$300 per student
Does not apply to services at
the Student Health Services, InNetwork Preventive Care
services, Office Visits with a
set-dollar copayment, or
Prescription Drugs.
The deductible applies to both
In-Network Provider and
Non-Network Provider
services, combined.
Yes, a $500 Additional
deductible for non-Anthem
Blue Cross PPO hospital or
residential treatment center or
ambulatory surgical center if
utilization review not obtained.
Why this Matters:
Yes, In-Network Provider per
student: $3,000
Non-Network Provider per
Student: $6,000
The out-of-pocket limit is the most you could pay in coinsurance during a coverage
period (usually 12 months) for your share of the cost of covered services. This limit helps
you plan for health care expenses. In-Network and Non-Network Provider out–of–pocket
limits are not combined. They accumulate separately.
You must pay all the costs up to the deductible amount before this plan begins to pay for
covered services you use. Check your Benefit Booklet to see when the deductible starts
over. See the chart starting on page 3 for how much you pay for covered services after you
meet the deductible.
You must pay all of the costs for these services up to the specific deductible amount
before this plan begins to pay for these services.
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 1 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Important Questions
What is not included in
the out–of–pocket
limit?
Is there an overall
annual limit on what
the plan pays?
Answers
Balance-Billed Charges, the
deductible, Health Care This
Plan Doesn't Cover, Premiums,
copayments, Additional
deductibles.
No. This policy has no overall
annual limit on the amount it
will pay each year.
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Why this Matters:
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
The chart starting on page 3 describes any limits on what the plan will pay for specific
covered services.
Does this plan use a
network of providers?
Yes, but you must seek care at
the Student Health Services
first. See
www.anthem.com/ca or call
1-866-940-8306 for a list of InNetwork providers.
You must begin all of your care at the Student Health Services, except in case of
emergency. They will provide a referral for care outside of the Student Health Service if
necessary. If you use an In-Network doctor or other health care provider, this plan will pay
some or all of the costs of covered services. Be aware, your In-Network doctor or hospital
may use an out-of-network provider for some services. Plans use the term In-Network,
preferred, or participating for providers in their network. See the chart starting on page 3
for how this plan pays different kinds of providers.
Do I need a referral to
see a specialist?
Yes, you need written referral
from the Student Health
Services to see a specialist.
There may be some providers
or services for which referrals
are not required. Please see the
Benefit Booklet of coverage for
details.
This plan will pay some or all of the costs to see a specialist for covered services, but only if
you have the Student Health Services referral to see the specialist.
Are there services this
plan doesn’t cover?
Yes.
Some of the services this plan doesn’t cover are listed on page 11. See your Benefit Booklet
for additional information about excluded services.
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 2 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Glossary
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance is your share of the costs of a covered service, calculated as a percentage of the allowed amount for the service. For example, if
the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 10% would be $100. This may change if
you haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use an In-Network Provider by charging you lower deductibles, copayments and coinsurance amounts.
A Referral is a written authorization given by the Student Health Services to seek care outside of the Student Health Services for medically
necessary care.
Common
Medical Event
If you visit a health
care provider’s office
or clinic
Services You May Need
Your Cost If
You Use a InNetwork
Provider
Your Cost If
You Use a NonNetwork
Provider
$15
Primary care visit to treat an injury or illness
Copayment/Visit
40% Coinsurance
$20
Copayment/Visit
40% Coinsurance
Specialist visit
Limitations & Exceptions
The insured student must obtain any
non-emergency medical care from the
Student Health Services.
The insured student must obtain a
referral from the Student Health
Services prior to seeking care with a
specialist.
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 3 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Your Cost If
You Use a InNetwork
Provider
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Your Cost If
You Use a NonNetwork
Provider
Chiropractor
A referral is required from the
Student Health Services prior to
seeking care with a chiropractor.
Chiropractor
$20 Copayment
per visit
Other practitioner office visit
Acupuncture
$20 Copayment
per visit
Limitations & Exceptions
40% Coinsurance
Acupuncturist
Coverage is limited to a total of 20
visits at Student Health Services, InNetwork Providers and NonNetwork Providers combined per
Benefit Year. A referral is required
from Student Health Services prior to
seeking care from an acupuncturist.
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 4 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Preventive care/cancer
screening/*immunizations/Well-woman
and contraceptive care
Diagnostic test (x-ray, blood work)
If you have a test
Imaging (CT/PET scans, MRIs)
Your Cost If
You Use a InNetwork
Provider
No Charge
20% Coinsurance
for Lab and X-Ray
20% Coinsurance
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Your Cost If
You Use a NonNetwork
Provider
40% Coinsurance
40% Coinsurance
for Lab and X-Ray
40% Coinsurance
Limitations & Exceptions
*Services are to be provided at the
Student Health Services unless the
student obtains a referral from
Student Health. The following is a
partial list of immunizations covered
at 100%: Diphtheria, Tetanus,
Pertussis, Measles, Mumps, Rubella,
Varicella, Influenza, Hepatitis A,
Hepatitis B, Pneumococcal,
Meningococcal, Polio, and Human
Papillomavirus (HPV).
All other immunizations are covered
at 80% In- Network Providers and
60% Non-Network Providers.
A referral from the Student Health
Services is required.
A referral from the Student Health
Services is required.
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 5 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Your Cost If
You Use a InNetwork
Provider
Your Cost If
You Use a NonNetwork
Provider
Generic drugs
$5 Copayment
(Student Health
Services
Pharmacy)/$10
Copayment (retail)
$10+any amount over
the contracted rate
(retail only)
Preferred brand drugs
$25 Copayment
(Student Health
Services
Pharmacy)/$40
Copayment (retail)
$40+any amount over
the contracted rate
(retail only)
Non-preferred brand drugs
$40 Copayment
(Student Health
Services
Pharmacy)/$100
Copayment (retail)
$100+any amount
over the contracted
rate (retail only)
Services You May Need
If you need drugs to
treat your illness or
condition
More information
about prescription
drug coverage is
available at
www.ventegra.net
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Limitations & Exceptions
Covers up to a 30 day supply (retail
pharmacy)
Covers up to a 30 day supply (retail
pharmacy)
Covers up to a 30 day supply (retail
pharmacy)
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 6 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Your Cost If
You Use a InNetwork
Provider
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Your Cost If
You Use a NonNetwork
Provider
A referral from the Student Health
Services is required. If you use UCSD
Medical Center, your coinsurance
will be waived.
A referral from the Student Health
Services is required. If you use a
UCSD physician, your coinsurance
will be waived.
20% Coinsurance
40% Coinsurance
20% Coinsurance
40% Coinsurance
Emergency room services
$100 Copayment
$100 + anything
above the allowed
amount.
Copayment is waived if admitted
inpatient. This is for the
hospital/facility charge only.
Emergency medical transportation
20% Coinsurance
for ground
ambulance/no
charge for air
ambulance
20% Coinsurance
for ground
ambulance/no charge
for air ambulance
The percentage of coverage is based
on billed charges
Urgent care
$50
Copayment/Visit
40% Coinsurance
Costs may vary by site of service. You
should refer to your Benefit Booklet
for details.
Facility (e.g., ambulatory surgery center)
If you have outpatient
surgery
Physician/surgeon
If you need
immediate medical
attention
Limitations & Exceptions
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 7 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Facility (e.g., hospital room)
Your Cost If
You Use a InNetwork
Provider
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Your Cost If
You Use a NonNetwork
Provider
20% Coinsurance
40% Coinsurance
20% Coinsurance
40% Coinsurance
If you have a hospital
stay
Physician/surgeon
Limitations & Exceptions
Failure to obtain preauthorization
may result in non-coverage or an
additional $500 deductible for
Non-participating providers, waived
for emergency admissions. A referral
is required from the Student Health
Services for non-emergency care. If
you use UCSD Medical Center, your
coinsurance will be waived.
A referral from the Student Health
Services is required. If you use a
UCSD physician, your coinsurance
will be waived.
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 8 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Mental/Behavioral health office visit and
outpatient services
If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health services during a
hospital stay
Substance use disorder office visit and
outpatient services
Substance use disorder services during a
hospital stay
If you are pregnant
Prenatal and postnatal care
Your Cost If
You Use a InNetwork
Provider
$15 Copayment
per Office Visit for
20% Coinsurance
for Facility
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Your Cost If
You Use a NonNetwork
Provider
40% Coinsurance
for Office Visit and
Facility
20% Coinsurance
40% Coinsurance
$15 Copayment
per Office Visit for
20% Coinsurance
for Facility
40% Coinsurance
for Office Visit and
Facility
20% Coinsurance
40% Coinsurance
$15 Copayment
for initial visit only. 40% Coinsurance
All other visits have
no charge.
Limitations & Exceptions
A referral from the Student Health
Services is required.
This is for facility professional
services only. Please refer to “hospital
stay” for facility fee coverage. A
referral from the Student Health
Services is required, except in an
emergency.
A referral from the Student Health
Services is required.
This is for facility professional
services only. Please refer to hospital
stay. A referral from the Student
Health Services is required.
A referral from the Student Health
Services is required.
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 9 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Delivery and all related services
Home health care
20% Coinsurance
No charge
Your Cost If
You Use a NonNetwork
Provider
40% Coinsurance
40% Coinsurance
Limitations & Exceptions
A referral from the Student Health
Services is required. If you use UCSD
Medical Center for delivery, your
coinsurance will be waived.
A referral from the Student Health
Services is required.
A referral from the Student Health
Services is required.
A referral from the Student Health
Services is required.
$20 Copayment
per visit
$20 Copayment
per visit
40% Coinsurance
Skilled nursing care
20% Coinsurance
40% Coinsurance
A referral from the Student Health
Services is required.
Durable medical equipment
20% Coinsurance
40% Coinsurance
A referral from the Student Health
Services is required.
Hospice service
20% Coinsurance
40% Coinsurance
A referral from the Student Health
Services is required.
Rehabilitation services
If you need help
recovering or have
other special health
needs
Your Cost If
You Use a InNetwork
Provider
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Habilitation services
40% Coinsurance
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 10 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your Benefit Booklet for other excluded services.)
Cosmetic surgery
Dental care (Adult)
Erectile dysfunction medications
Exams or tests required for participation in an
academic, recreational, or employment activity
Experimental or unnecessary medical
treatment
Infertility diagnosis & treatment
Intercollegiate sports injuries
Long-term care
Private-duty nursing
Routine eye care
Routine foot care unless you have been
diagnosed with diabetes. Consult your Benefit
Booklet.
Services performed without a Student Health
referral
Weight Loss programs
Work-related conditions covered by Workers
Compensation
Other Covered Services (This isn’t a complete list. Check your Benefit Booklet for other covered services and your costs for these services.)
Bariatric surgery is covered only for morbid
obesity
Hearing aids (every 4 years)
Newborn coverage for 1st 31 days ($25,000
maximum)
Psycho-educational testing
Sex Reassignment Surgery
Most coverage provided outside the United
States. See
www.bcbs.com/bluecardworldwide. See
the UC SHIP Benefit Booklet for Medical
Evacuation and Repatriation benefits
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 11 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Your Rights to Continue Coverage:
If you lose coverage under the plan, you may be eligible for Conversion to an Anthem Blue Cross Individual plan. The premium may be significantly higher
than the premium you pay while covered under this plan and the benefit plan design will be different.
For more information on your rights to continue coverage, contact the plan at 1- 800-777-6000. You can review instructions for enrolling in an Anthem
Blue Cross Individual Conversion plan at www.ucop.edu/ucship, click on your campus in the left navigation bar, then click on Medical Services under
Online Services, and scroll down to Conversion Enrollment Information.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact:
Anthem BlueCross
ATTN: Appeals
P.O. Box 4310
Woodland Hills, CA 91365-4310
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 12 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Language Access Services:
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 13 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
About these Coverage
Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is not
a cost
estimator.
Don’t use these examples
to estimate your actual
costs under this plan. The
actual care you receive will
be different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information
about these examples.
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $6960
 Patient pays $580
 Amount owed to providers: $5,400
 Plan pays $4690
 Patient pays $710
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
Patient pays:
Deductibles
Copayments
Coinsurance
Limits or exclusions
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
$200
$60
$320
0
$580
Patient pays:
Deductibles
Copayments
Coinsurance
Limits or exclusions
Total
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
$2,900
$1,300
$700
$300
$100
$100
$5,400
$200
$330
$180
$0
$710
Page 14 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy (SHS) UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PPO
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any student covered under this plan.
Out-of-pocket expenses are based only
on treating the condition in the example.
The patient received all care from InNetwork providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
show?
Does the Coverage Example
predict my future expenses?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayment, and coinsurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
No. Coverage Examples are not cost
Does the Coverage Example
predict my own care needs?
 No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your own
costs will be different depending on the care
you receive, the prices your providers charge,
and the reimbursement your health plan
allows.
Can I use Coverage Examples
to compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 15 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.
University of California Student Health Insurance Plan (UC SHIP)
Student Health Services & Pharmacy UC San Diego
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 2013-2014 Plan Year
Coverage for: Student| Plan Type: Custom PP
Are there other costs I should
consider when comparing
plans?
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-ofpocket costs, such as copayment,
deductibles, and coinsurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket
expenses.
Questions: Call 1-866-940-8306 or visit us at www.ucop.edu/ucship
If you aren’t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can also view the Glossary
at www.anthem.com/ca or call 1-866-940-8306 to request a copy.
Page 16 of 16
The University of California Student Health Insurance Plan is a self-funded Student Health Plan which voluntarily complies with the benefits of the Affordable Care Act.